1.County?

2.County Contact Information?

Name

Address

Address 2

City/Town

State/Province

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code

Email Address

Phone Number

3.County HHS Budget?

4.Staff Size?

5.Funding Sources: General Funds v. Grants Percentage

General Funds:

Grants:

Other Sources:

6.Population of County?

7.County HHS Programs

Veterans Services

Affordable Housing

Aging & Adult Programs

Family Stability Services

Healthcare Services

Food Assistance

Children Services

Homelessness

Indigent Burial Services

Baker/Marchman Act Payment

Prescription Drug Assistance

Rental and/or Utility Assistance

Non-Profit Funding

HCRA

Social Services

Other (please specify)

8.For all boxes checked above, for each program please provide details

Veterans Services

Affordable Housing

Aging & Adult Programs

Family Stability Services

Healthcare Services

Food Assistance Porgrams

Children Services

Homelessness Services

Indigent Burial Services

Baker/Marchman Act Services

Prescription Drug Assistance Programs

Rental and/or Utility Assistance Programs

Non-Profit Funding

HCRA

Social Services

Other Programs

9.IdentifyAnnual Grant Funding County Receives

10.Identify Grant Funding in Danger of Being Eliminated